Management and Treatment of Omental Caking
The management of omental caking requires surgical cytoreduction with the goal of complete tumor debulking, as this approach offers the best chance for improved survival in patients with advanced ovarian cancer.
Definition and Diagnosis
Omental caking refers to diffuse metastatic infiltration of the omentum, most commonly associated with advanced ovarian carcinoma. It presents as a characteristic radiographic finding where the omentum appears thickened and cake-like due to tumor infiltration.
Diagnostic Features
- CT scan is the most reliable radiographic technique for evaluating omental pathology 1
- MRI features that suggest malignant omental caking include:
- Hyperintensity on diffusion-weighted imaging (DWI)
- Hyperenhancement on contrast studies
- Convex outer omental contour
- Discrete omental nodules 2
Treatment Approach
Surgical Management
Complete cytoreductive surgery
- Primary treatment goal for omental caking, particularly in ovarian cancer
- Aims to remove all visible tumor deposits
- May require extensive procedures including:
- Omentectomy
- Multiple digestive tract resections 3
- Complete debulking significantly improves prognosis
Surgical considerations
- Presence of omental caking is associated with higher rates of incomplete resection
- When complete debulking is achieved, cases with omental caking typically require more extensive digestive tract resections 3
- Surgical planning should account for potential need for multivisceral resection
Adjuvant Therapy
- Chemotherapy
- Essential component following surgical debulking
- Can achieve significant reduction in omental metastases
- Near-complete resolution of omental metastases has been demonstrated after completion of chemotherapy cycles 4
- Typically platinum-based regimens for ovarian cancer
Prognostic Implications
- Omental caking is considered a negative prognostic factor in advanced-stage ovarian cancer
- The presence of omental cake significantly diminishes the rate of complete cytoreduction compared to cases without this finding 3
- Successful treatment (combination of surgery and chemotherapy) can lead to resolution of omental metastases as demonstrated on follow-up imaging 4
Monitoring and Follow-up
- Serial imaging (CT or MRI) to assess treatment response
- Regular clinical assessment for disease recurrence
- Tumor marker monitoring when applicable (e.g., CA-125 for ovarian cancer)
Clinical Pitfalls
- Benign omental thickening (as seen in portal hypertension) can mimic malignant omental caking
- Differentiation requires careful radiological assessment using multi-parametric MRI 2
- Omental infarction is a rare condition that can present with acute abdomen and may be confused with other acute conditions 5
Treatment Challenges
- Complete surgical debulking may not be technically feasible in all patients
- Extensive surgical procedures carry significant morbidity risks
- Treatment decisions should balance aggressive surgical approach with patient's overall condition and comorbidities
The presence of omental caking significantly impacts surgical planning and outcomes, requiring experienced surgical teams familiar with advanced cytoreductive techniques to achieve optimal results.